H.R. 5813 — Women’s Health and Cancer Rights Modernization Act of 2025

This section requires group health plans and health insurance issuers offering group or individual health insurance coverage that provide medical and surgical benefits for breast cancer treatment to cover specified breast or chest wall reconstruction items and services elected by a participant or beneficiary, including (1) extirpation or treatment of diseased or damaged breast tissue (i.e., mastectomy and breast-conserving surgery); (2) all modalities of reconstruction (i.e., implant-based, tissue-based, and future modalities recognized in Healthcare Common Procedure Coding System (HCPCS) Level I); (3) all types within each modality (i.e., immediate or delayed implant-based, specified tissue flaps or fat grafting, combined approaches, and future types in HCPCS Level I); (4) all procedural variations noted in HCPCS Level I code descriptors; (5) all stages of reconstruction (including flat closure); (6) surgery on the contralateral breast or chest wall for symmetry; (7) custom-fabricated breast prostheses (including replacements); and (8) treatment of physical complications (including lymphedema compression items as defined in SSA §1861(mmm) without regard to the January 1, 2024, effective date). Coverage must be provided in consultation with the attending physician and patient, subject to annual deductibles and coinsurance consistent with other benefits; plans and issuers must ensure at least one in-network provider for each modality, type, and procedural variation; provide specified written notices upon enrollment and annually; and prohibit denying eligibility or renewal to avoid these requirements or penalizing providers. The section adds new PHSA §2799A-11, makes a conforming amendment to PHSA §2727, and amends ERISA §713; it permits reimbursement negotiations and does not preempt state laws requiring equivalent or greater coverage. (As background, these requirements expand on existing Women's Health and Cancer Rights Act protections for post-mastectomy reconstruction by specifying modalities/types/procedures, guaranteeing in-network access, and including chest wall reconstruction and lymphedema treatment without date limits.)